Economic conditions

Economic conditions of primary care, which is the second structure dimension in the framework, are largely determined by the proportion of total health expenditures spent on primary care and the financial conditions for access to care for patients. Cost-sharing and co-payment can threaten equity in financial access to care. Furthermore, financial incentives for health care workers can play a role. Primary care professionals can be salaried or self-employed providers, either contracted or not to the health services or health insurance system.

The employment status and mode of remuneration may also influence the attractiveness of primary care professions.

The next section will discuss the four features of the economic conditions of primary care (see Appendix I for an overview of the features and indicators).

Table 2.2 provides an overview of results of the economic conditions of primary care by country.

Primary care expenditure

Primary care expenditure strongly varies among countries. To some extent this results from the services included in the expenditures for primary care. A uniform methodology for calculating primary care expenditure across countries is not available and this hampers the comparability of this indicator. For example, in some countries it is limited to costs for family practice only, while in others freely accessible specialist care services are also included. Additionally, costs for community nursing, primary mental health care, dentistry and emergency care may be included in primary care costs. Even in family practice fund-holding, elements for laboratory tests and other investigations can be included. Finally, uniformity in the allocation of costs of prescribed medicines is absent.

Given these reservations, for 21 of 31 countries a comparison can be presented on primary care expenditure. In these countries the share varied from 4.7% in the Czech Republic to 25.6% in Switzerland. The share of prevention and public health expenditure varied from 0.6% in Cyprus to 18.4% in the Netherlands. It is difficult to draw comparisons from these data because of the wide variability in calculating expenditure.

Primary care benefits package

In general, the coverage of the population for medical expenses is quite comprehensive. In half of the countries coverage for primary care costs is complete, while most of the other half have coverage close to that. There are two exceptions: Cyprus with 80% and Ireland with 33%. For Turkey no exact data on coverage were available. In most countries the coverage for prescribed

medicines is close to the coverage for primary care costs in general, with the exception of Bulgaria, where the coverage for prescribed medicines is 40%.

No data were available for Romania and Turkey. In Cyprus the coverage for medicines is complete, and thus better than the overall coverage for primary care services.

Employment status of GPs

Countries differ in the dominant employment status of primary care providers, in particular GPs. In the following 18 countries GPs are predominantly self-employed: Belgium, Bulgaria, the Czech Republic, Denmark, Estonia, Germany, Hungary, Ireland, Italy, Latvia, Luxembourg, the Netherlands, Norway, Romania, Slovakia, Switzerland, Turkey and the United Kingdom.

In these countries the large majority of self-employed GPs usually have contracts with health insurance or a health authority.

In Finland, Iceland, Lithuania, Poland, Portugal, Slovenia, Spain and Sweden all or most GPs are salaried either with the national, regional or local authorities or by other GPs. In most of these countries health care is funded through governmental budgets, not by health insurance. Countries with salaried GPs often offer them the possibility to work part-time in private practice.

The payment scheme of independently working GPs is usually a mix of capitation and fee-for-service payment. Fee-for-service payment is only reported for Cyprus, France and Switzerland. In half of the countries with salaried GPs these have a flat salary while in the other half the salary is combined with pay-for-performance elements and related to the number of patients served.

The comparison of annual income of GPs is complex as different components are included in the overall income in the countries. In some countries practice costs, practice staff costs and even costs for laboratory expenses are included.

In countries where the data do not include practice costs, the average estimated annual income of a GP ranges from €10 782 in Lithuania to €150 000 in Luxembourg. In the group of countries where the data include practice costs, it varies from €13 688 in Bulgaria to €71 514 in Belgium. Comparisons of net incomes are even more difficult as taxation systems strongly differ.

As the level of funding of health care and primary care in a country are related to indicators of economic development, it is not surprising that, in general, in countries with a high gross domestic product (GDP) GPs have relatively high incomes as well. However, there are other determinants of the income of GPs, as the different income positions of GPs in the high-GDP countries Belgium and the United Kingdom show.

Table 2.2 Economicconditionsofprimarycare,overviewofselectionofresultsbycountry

Country PCexpenditureas%of totalHE^’year Prevention&publichealth

expenditureas%oftotal HE^’year

%populationuninsuredfor medicalexpenses

%populationinsuredfor PCcosts

%pop.insuredfor medicinesprescribedinPC

DecentralizationofPCresponsibilities(level)

Remunerationsystemfor salariedGPs Remunerationsystemfor self-employedGPs Averagegrossannual incomeofGPsinEUR^’year (incl.=incl.practicecosts)

salariedwithnat.,reg.

orlocalauthorities salariedwithother physicians self-employedwith

contracttohealth insurancefund(s)or healthauthority self-employedwithout

contract(paidby patientsout-of-pocket)

Austria–1.8’072.098.098.049.0–20.429.1FlatsalaryMixofcapitation,FFS &othercomponents90852.98’05 Belgium19.0’103.9’07<199.099.0–0.399.7–FlatsalaryMixofcapitation,FFS &othercomponents71514.00’09(incl.) Bulgaria6.0’103.5’065–1095.035–40–13.486.6–FlatsalaryMixofcapitation,FFS &othercomponents13688.51’09(incl.) Cyprus10.0’100.6’0610.080.010050.0––50.0FlatsalaryFFSpayment55000.00’09 CzechRepublic4.7’072.2’0701001001.04.095.0–FlatsalaryMixofcapitation&FFS25000.00’10 Denmark–1.4’07098.0100100––Mixofcapitation&FFS135000.00’10 Estonia7.1’092.6’074.495.695.6–5.095.0–FlatsalaryMixofcapitation,FFS &othercomponents17500.00’08 Finland–5.4’070100100100–––Salaryrelatedto bothpatientsnr. &perform.indicators–64253.79’07 France19.3’102.6’080.194.694.5531.759.80.2FlatsalaryFFSpayment (optionalP4P)125659.00’06 Germany–4.0’080.299.899.83.010.087.0–FlatsalaryMixofcapitation&FFS84300.00’07 Greece22.9’97––100–50.050.0FlatsalaryFFSpayment25000.00’09(–) Hungary10.3’102.4’10<11001004.01.095.0–FlatsalaryMixofcapitation,FFS &othercomponents35500.00’10(incl.) Iceland–0.7’105.0100–90.0–5.05.0FlatsalaryFFSpayment70000.00’09

Ireland13.0’093.5’0550.033.030.0––80.020.0–Mixofcapitation&FFS110000.00’09 Italy5.7’083.6’075.0100100––100––Mixofcapitation,FFS &othercomponents50000.00’10(incl.) Latvia9.7’091.2’0901001008.0–90.02.0Salaryrelatedtoboth patientsnr.&perform. indicatorsMixofcapitation,FFS &othercomponents45000.00’08(incl.) Lithuania13.8’091.3’065.099.095.080.0–19.01.0Salaryrelatedtoboth patientsnr.&perform. indicatorsMixofcapitation &FFS10782.00’09 Luxembourg–1.1’052.197.910010.0–90.0–FlatsalaryFFSpayment150000.00’08 Malta–––10010035.0–65.0FlatsalaryFFSpayment10.808,30’99(–) Netherlands14.7’0818.4’051.099.099.015.085.0–FlatsalaryMixofcapitation&FFS112464.90’06 Norway5.8’081.9’0801001007.0–93.0–FlatsalaryMixofcapitation&FFS115000.00’10(incl.) Poland13.3’092.2’072.397.797.776.024.0FlatsalaryMixofcapitation&FFS38400.00’09(incl.) Portugal–1.8’06010010099.01.0––Salaryrelatedtoboth patientsnr.&perform. indicators–60000.00’09 Romania10.2’085.9’060100––24.0–76.0Salaryrelatedtoboth patientsnr.&perform. indicatorsMixofcapitation&FFS31818.00’08(incl.) Slovakia8.0’104.5’0601001000.50.599.0–FlatsalaryMixofcapitation,FFS &othercomponents12000.00’09 Slovenia12.2’084.1’060.0910010072.0–28.0–Salaryrelatedtoboth patientsnr.&perform. indicatorsMixofcapitation&FFS44877.00’08 Spain14.1’052.2’07010010080.0–20.0–Salaryrelatedtoboth patientsnr.&perform. indicatorsMixofcapitation,FFS &othercomponents45000.00’09 Sweden–3.5’070100100Majority––Flatsalary–54870.00’10 Switzerland25.6’072.3’070.899.299.2––90.0>––FFSpayment126006.00’05 Turkey–2.3’0012.7––––100––Mixofcapitation,FFS &othercomponents27000.00’10 UnitedKingdom19.9’07 (ENG)4.0’07(ENG)010010020.073.0–Salaryrelatedtoboth patientsnr.&perform. indicators Mixofcapitation,FFS &othercomponents133000.00’07

Overall economic conditions of primary care by country

Fig. 2.2 provides an overview of the total economic conditions of primary care scores by country, considering the performance of each country on all economic conditions indicators (see Appendix II for an overview of the features and indicators used for the scores). The figure shows that the general economic conditions of primary care are most favourable in Belgium, Denmark, Finland, Germany, Italy, the Netherlands, Portugal, Slovenia, Spain and the United Kingdom. Countries where economic conditions for primary care are relatively poor are Bulgaria, Cyprus, the Czech Republic, Greece, Iceland, Ireland, Malta, Romania, Sweden and Turkey.

The variation between countries in the overall economic conditions of primary care is limited; scores range from 1.90 in Bulgaria to 2.26 in the United Kingdom. Still, there seems to be room for improvement in some countries on specific indicators. The expenditure on primary care, for instance, is relatively low in Bulgaria, the Czech Republic, Estonia, Italy, Latvia, Norway and Slovakia. Another point is that in 10 out of 31 countries primary care expenditure data could not be identified in the total health expenditures.

Concerning the income of providers, a major observation is the considerable gap in most countries between the financial status of primary care providers compared to hospital specialists. The only countries where GPs have a financial status comparable to medical specialists are Cyprus, the Czech Republic, Hungary, Ireland, Portugal, Spain and the United Kingdom. In all other countries, the income of GPs is, usually considerably, lower than the income of most medical specialists. However, in these countries GPs earn considerably more than nurses and allied health care professionals.

No significant relationship was found between the national income (GDP) of countries and their overall economic conditions of primary care. This suggests that the financial policies and mechanisms applied are of greater influence than the financial resources available.

Fig. 2.2

Totaleconomicconditionsofprimarycarescorebycountry (scale1(low)–3(high))

1 1.5 2 2.5 3

Bulgaria Ireland Iceland Cyprus Malta Czech Republic Greece Luxembourg Norway Poland Estonia Lithuania Latvia Hungary Sweden Slovakia Denmark Portugal Austria France Switzerland Turkey Romania Italy Germany Slovenia Finland Netherlands Belgium Spain United Kingdom